This morning, I listened as family members remembered their loved ones at the opening of a coroner’s inquest into four deaths at the Toronto South Detention Centre. As photos of the men appeared on the screen, I was reminded why inquests like this one matter so much.
For these families, this inquest is the best, and possibly the only, chance to get clear answers about what happened. These four men were incarcerated by the Province of Ontario. They depended entirely on the province for their survival. Ontario controlled what they ate, when they ate, and when and whether they received health care. Nelson Mandela observed that no one truly knows a nation until they have been inside its jails.
What an Inquest Does That Nothing Else Can
An inquest is often the only way families receive full information about how their loved one died. It is also often the only moment the government faces public accountability for the systemic problems behind deaths in custody: overcrowding, inadequate health care, poor responses to crises, and chronic understaffing.
No other tool in our legal system allows for this kind of public scrutiny:
- A criminal trial looks backward. It asks whether a specific accused person is guilty of causing a specific death.
- A civil lawsuit also looks backward. It asks what damages the government owes for negligence that led to a death.
- An inquest looks both backward and forward. The jury establishes the facts of what happened, examines the systemic issues at play, and makes recommendations to prevent future deaths.
The Government’s Proposal
In December 2025, the Ontario government announced plans to change the Coroners Act to end mandatory inquests into non-natural deaths in Ontario jails and federal prisons in Ontario, replacing them with an annual review of deaths in correctional facilities conducted by the coroner’s office. (See The Globe and Mail’s coverage.)
This proposal is an attempt to avoid public scrutiny and accountability for the deaths of people who are completely dependent on the state.
Who Loses If Mandatory Inquests End
Families. Inquests shine a light on failures in the system and give families answers and a measure of closure. A line in a statistical report cannot do that.
People who are incarcerated. Inquest recommendations directly shape the conditions of people living in Ontario’s jails today.
All of us. Inquests show that we value every human life and expect our government to do everything in its power to preserve it.
Replacing individual inquests with an annual statistical report is a step away from government accountability. And once we accept that the government can act without direct accountability toward people in its custody, we should expect it to try to avoid accountability elsewhere too.
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